Healthcare Provider Details

I. General information

NPI: 1194988915
Provider Name (Legal Business Name): DIMITRI NICHOLAS PAGOULATO PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6516 E MYRTLE AVE
BAKER LA
70714-4348
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-774-7320
  • Fax: 225-774-5432
Mailing address:
  • Phone: 225-774-7320
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number200193
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: